Intermountain-led CMS Hospital Engagement Network Falls Prevention October 10, 2014 Affinity Call Marlyn Conti, BSN, MM, CPHQ Patient Safety Initiatives Manager Intermountain Healthcare Quality and Patient Safety Jason Scott, MPH, MPP Carlos Barbagelata, MS Outline for Discussion • • • • • Review of data through Q2 2014 ‘High performers’ – Identify and ask what they are doing? Falls recommended metrics “Just-one-thing” – updated document 2014/15 plans • Reach out to low performers to provide assistance • Continue Webinars for sharing? • 2015? Overall Progress Through Q1 2014 Overall Progress Through Q2 2014 Intermountain HEN 2012- Q2 2014 submitting Inpatient Falls with Injury High Performing Benchmark: 0.50 Intermountain HEN 2012- Q1 2014 submitting Inpatient Falls with Injury Intermountain HEN 2012-Q1 2014 submitting Hospitals Inpatient Falls High Performing Benchmark: 2.15 Intermountain HEN 2012-13 submitting Hospitals Inpatient Falls HEN Falls Measures • Metric specification resource manual http://www.henlearner.org/wpcontent/uploads/2012/03/HEN_measure_Feb5.pdf • Submission schedule: • Nov 20, 2014: for data through August 2014 HEN Falls Measures Inpatient Falls HEN Falls Measures Falls with Injury High Performing Hospital Highlight… Most Improvement Inpatient Falls Most Improvement Lowest Rates BAYLOR ALL SAINTS MEDICAL CENTER AT FW BAYLOR ALL SAINTS MEDICAL CENTER AT FW HEBER VALLEY MEDICAL CENTER MENLO PARK SURGICAL HOSPITAL DELTA COMMUNITY MEDICAL CENTER OREM COMMUNITY HOSPITAL AMERICAN FORK HOSPITAL BAYLOR REGIONAL MEDICAL CENTER AT GRAPEVINE HEBER VALLEY MEDICAL CENTER SUTTER COAST HOSPITAL GARFIELD MEMORIAL HOSPITAL BAYLOR REGIONAL MEDICAL CENTER AT GRAPEVINE SUTTER MATERNITY & SURGERY CENTER OF SANTA CRUZ CASSIA REGIONAL MEDICAL CENTER EDEN MEDICAL CENTER ESPANOLA HOSPITAL PROVIDENCE HOOD RIVER MEMORIAL HOSPITAL DELTA COMMUNITY MEDICAL CENTER AMERICAN FORK HOSPITAL BAYLOR MEDICAL CENTER AT WAXAHACHIE High Performing Hospital Highlight… Most Improvement Inpatient Falls with Injury Most Improvement Lowest Rates BAYLOR HEART AND VASCULAR HOSPITAL BAYLOR ALL SAINTS MEDICAL CENTER AT FW BAYLOR ALL SAINTS MEDICAL CENTER AT FW BAYLOR REGIONAL MEDICAL CENTER AT GRAPEVINE DELTA COMMUNITY MEDICAL CENTER THE HEART HOSPITAL BAYLOR PLANO AMERICAN FORK HOSPITAL PROVIDENCE MEDFORD MEDICAL CENTER PROVIDENCE NEWBERG MEDICAL CENTER BAYLOR MEDICAL CENTER AT CARROLLTON PROVIDENCE MEDFORD MEDICAL CENTER SUTTER SOLANO MEDICAL CENTER SUTTER COAST HOSPITAL BAYLOR MEDICAL CENTER AT WAXAHACHIE UPPER CONNECTICUT VALLEY HOSPITAL SUTTER SOLANO MEDICAL CENTER SUTTER DAVIS HOSPITAL SUTTER MATERNITY & SURGERY CENTER OF SANTA CRUZ SUTTER DAVIS HOSPITAL AMERICAN FORK HOSPITAL Just One Thing Matrix Recommendations Getting Started Working Harder Ahead of the Curve Implement standard Assessment tools, protocols and prevention strategies Appoint “leads” to drive improvement & identify or champion teams that includes unit level nursing, quality, patient safety, physical therapy and pharmacy services. (high level of evidence) Implement decision algorithms and/or computerized decision support in the electronic medical record to target interventions based on patient specific risk factors (high level of evidence) Getting Started and Keeping it going! • Set Organizational priority • Identify Risks and Gaps • Develop Monitoring Systems • Designate Champions • Integrated Nurse Charting and Care Plans • Repeat Cycles of ‘Plan-Do-study-Act’ Falls Bundle & Falls Survey Report Falls Bundle • Measurement • Inpatient falls rate • Falls/Patient Days • Fall-related injuries/patient days • CMS Hospital Acquired Conditions (HAC) rates • Assisted vs unassisted falls • Assessment & Reassessment • Standard risk assessment tool (standardized across all care settings) • Policy for timing of assessment • Reassess when condition changes and after procedures Falls Bundle • Interventions • Signage • Door frame magnet/Door signs • Patient/Family Education • Standard FAQ sheet • Room environment • Bed low, room free of clutter, side rails up, bed alarms on • Visibility • Made reminders larger and brighter (yellow blankets, slippers, etc) • Fall prevention protocol recorded in medical record • Hourly rounding made part of falls protocol • Safe Patient Handling (no lift) policy Falls Bundle • Patient Family Education • Standardized education content • Available as applicable just-in-time), online, etc • Validation that learning has occurred such as a teach-back concept or skills pass-off. • Staff Education & Learning • Standardized education contend on hire • Annual skills fairs • Annual assigned learning modules • Leadership/Structure • • • • Fall prevention team Integration with quality and patient safety plan and structure Unit level & hospital level Fall Prevention champions Post fall huddles and fall evaluation/questionnaire Falls Bundle • Equipment • Beds • Standard models where possible, reduces learning needs and maintenance issues • Bed Alarms • Integrated with nurse call systems when possible • Lifting Equipment • Available and in use (portable, overhead, and transfer such as gait belts, slider sheets/boards, etc.) • Nurse Call System • Integrated with beds and/or communication devices • Environmental Safety • Electrical outlets, lips on doorways Falls Survey Results 1. What facility are you from? 17 Facilities Responding Baylor Baylor Scott & White Hillcrest Medical Center - Waco Texas Dr. Dan C. Trigg Memorial Hospital Intermountain Medical Center Intermountain SWR Mayo Clinic Health System - Franciscan Healthcare Mayo Clinic Health System - Northland McKay Dee Presbyterian Ph-Main campus Primary Children's Hospital Providence St. VIncent Medical Center Regions Hospital, St. Paul, Minnesota Riverton Sanpete Valley Hospital Sutter Medical Center Santa Rosa, Ca Upper Connecticut Valley Hospital VVMC 2. What is your role at your facility? Answer Response % Quality 11 44% Nursing 10 40% Other (Specify) 4 16% Education 0 0% Total 25 100% Other (Specify) Patient Safety Nursing Quality Patient Safety Nurse Manager 3. What is the size of your facility? Answer Response % >200 people 19 73% 100 - 200 people 4 15% 20 - 49 people 3 12% 50 - 99 people 0 0% Total 26 100% 4. Does your facility have a leadership-appointed fall prevention team assigned to work on fall prevention? Answer Response % Yes 23 88% No 3 12% Total 26 100% 4a. Is your fall prevention team multidisciplinary? (if yes, which disciplines are included?) Answer Response % Yes 19 86% No 3 14% Total 22 100% Yes PT, Pharmacy, Risk, Dietary nursing, PT/OT, patient safety, facility safety and security, occupational health, physicians nursing, PT/OT, Security, Education, IT, Radiology, Quality Rehab, Transportation, Environmental Services, Lab, Nutrition Safety officer, lift team, Nursing (bedside, managers and directors), Risk and quality members Nursing (Med/Surg, OR, Mental Health, ICU, Acute Rehab, ED), Pharmacy, Physical Therapy, Nursing Education, Patient Safety, nursing, PT, OT, pharmacy, resp, lab, physicans, Social work, and case management. Managemet, OT/PT, Pharmacy, Quality, Nursing PT, Pharmacy, employee health Nursing, PT, Imaging, Patient Relations, Security, Quality, Risk Nursing, Radiology, Lab, all outpatient areas, Risk, Quality, 4b. How frequently does your fall prevention team meet? (Check all that apply) Answer Response % Once a Month 15 65% 2-3 Times a Month 0 0% Once a Week 0 0% Other (e.g as-needed, etc.) 8 35% Other (e.g as-needed, etc.) Quarterly or more often as needed Have been once a month, now quarterly As-needed 5. What standard risk assessment tool do you use? Answer Response % Other 11 48% Morse 7 30% Hendrick 4 17% Hybrid Tool 2 9% Schmidt 0 0% Other Developed own EPIC Moving to Morse soon Combination of morse and our tool Johns Hopkins Unsure Tandem Intermountain tool Humpty-Dumpty in near future 6. Do you have bed exit alarms integrated with the nurse'scall system? Answer Response % Yes 18 69% No 8 31% Total 26 100% 7. Do you use a patient contract for falls risks? Answer Response % No 24 92% Yes 2 8% Total 26 100% 8. What tools do you use to educate patients/families about fall prevention? (check all that apply) Answer Response % Fact Sheets 18 75% Online materials 7 29% Other (specify) 12 50% Other (specify) Teaching by RN's and staff Verbal teaching regarding falls risk and interventions Verbal Education Teaching sheets Handout and verbal communication Whiteboards reminders, Discussion Face-to-face discussion Communication board, unit orientation, rounding In-room white boards 9. What tools do you use to educate staff about fall prevention? (check all that apply) Answer Response % Posters 19 76% Fact Sheets 16 64% Assigned Computer-Based Training 23 92% Other 11 44% Other Annual fall prevention workshop and online training Staff meetings Unit Based Falls Champion Shared Decision Making Staff meeting, post fall assessments, and review of cases Orientation checklists Post falls huddle, annual skills day Huddles, staff meetings, Metric Boards 1:1, unit fall champions, newsletter articles 10. With what frequency do you assign staff education? (Check all that apply). Answer Response % Annual 23 88% As-Needed 16 62% On Hire 11 42% Other (Specify) 3 12% Every Other Year 0 0% 11. Do you provide patient fall incidentevent reports for use by hospital staff managers and teams? (If yes, please describe how reports are distributed or made available). Answer Response % Yes 23 88% No 3 12% Total 26 100% 11. Do you provide patient fall incident event reports for use by hospital staff managers and teams? (If yes, please describe how reports are distributed or made available). Other Via email to unit managers and designated staff leaders Available via reporting system Staff meetings, Electronic Event System Information is discussed at meetings with leaders and at staff meetings. Patient information and outcomes are shared but never posted. Data about falls is posted in the nursing units Reports are viewed and managed at a local level of the location of the fall. Falls Prevention team analyzes the data from the reports to identify house-wide trends. Event reports are filled out online and can be accessed by managers and quality improvement staff. Postfall assessment are filled out and scanned to management, and falls committee representative Fall with injury reports are sent to unit managers post-fall debrief. Statistic reports are available via STATIT and a monthly report is shared to nursing managers at the monthly fall team meeting. Data from risk, collected by Quality, shared with staff, managers, leadership, governing board, and medical staff. Shared with managers who, in turn, educate and follow up with staff. Stats are shared with managers and staff. Fall reports for hospital and per units with monthly rate and rolling 6 month rate, also have fall prevention bundle audit data 12. What is the most successful approach that you feel has contributed to reducing patient falls? Text Response Getting staff involved in assessing their own unit readiness to prevent falls. Making it a goal with incentives for completion. Telling stories about falls and near misses. Integrating fall prevention with safe patient handling. The visuals applied: This helps all staff identify which patients are high risk falls.(i.e) Gait belts hanging on door frame, red booties on falls risk patients,bedside reporting also helps remind patient and family members. Proper equipment, staff training, frequent reminder of importance, keeping it in the forefront at all times Change in culture - falls are not expected or a natual part of being hospitalized. Constant vigilance; staff accountability; manager engagement; unit-based champions; current data - metrics; Falls prevalence monthly, multildisciplinary approach and the increase in lift equipment and the use of a lift team. Staff awareness, daily huddle focus, and education Root Cause and Common Cause Analysis with Direct Feedback to Staff, Units, Ministries. Assessment tools that identify high risk patients, bed alarms, chair alarms, pt's are designated as a falls risk on patient census board, and fall magnets are placed outside doors. If a fall occurs we do post fall assessment and identify any contributing factors and or trends. Partnering with family/caregivers to team up to prevent falls. Making our team multidisciplinary, Fall contracts and hourly rounding addressing the 4 Ps Bed alarms connected to call system. awareness when falls occur what the reasons were reported to quality and patient safety committee. clinical ladder RN project for 2014 Currently piloting. No One Walks Alone program. We got our infromation from Kaiser San Diego. Pilot has just begun but has provided data that it may have a profound impact on our overall fall rate. Repeat falls reduced by standardizing the interventions once a patient fell and the use of alarms to prevent falls Required monthly audits done by each unit to ensure our falls prevention strategies are in place - magnets, stickers, gait belts, bed alarms, white boards, risk scores etc. 13. To help us measure progress, please indicate your facility's program status since starting the HEN collaboration to reduce patient falls. A. "Getting Started": This level consists of implementing standard assessment tools, protocols and prevention strategies. B. "Working Harder": This level focuses on appointing "leads" to drive improvement and identify SWOT (or champion) teams that includes unit nurse. C. "Ahead of the Curve": This level focuses on implementing decision algorithms and/or computerized decision support in the EMR based on patient risk factors. What level do you feel your facility is at? Answer Response % Getting Started 6 24% Working Harder 10 40% Ahead of the Curve 9 36% Total 25 100% 14. What barriers are you experiencing that are preventing you fromachieving your goals to reduce patient falls? Fall Prevention Barriers Enough bandwidth to keep up the focus. Time, consensus, conflicting priorities. Staff shortages. Patient acuity and volume. Buy in from unit managers and their staff High falls risk patients inability to remember they can not ambulate on there own."Patients cognitive level" Equipment issues, Many changes in workflow. Accountability issues. Multiple competing priorities that seem to switch the focus away from fall prevention; increasing Nurse Patient Ratios; staff turnover; Consistency in standard implementation -- variability amoung staff performance. Dementia patients who can not find SNF placement related to behavior--longer stays increase risk Staff engagement with the process. Hospital does not bed alarms on every bed and alarms are not routed to the nurse call system. Staff perception with nursing ratios increasing is the hardest thing. There are certain things that are outside of our control no matter how hard we work and no matter what interventions we put into place! It's very frustrating.. Have been able to work through barriers. Zero falls with moderate or severe injury in 698 days (since we began monitoring in Nov 2012. 100% of staff staying in bathroom with patient and not "turning to get something outside of the bathroom" Consistently remembering bed alarms In children, falls don't usually cause expensive harm or injury as in adults, so leadership often overlooks the importance of fall prevention as a proactive process. Final Thoughts • 1. What changes have you made since joining the HEN to reduce falls? • 2. What have you done to recognize achievements in fall reduction?